John P. Moriarty

Comprehensive quality of discharge summaries at an academic medical center

BACKGROUND Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE To conduct a comprehensive quality assessment of discharge summaries. DESIGN Prospective cohort study. SUBJECTS Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

Chemistry in an Evolving Protoplanetary Disk: Effects on Terrestrial Planet Composition

The composition of planets is largely determined by the chemical and dynamical evolution of the disk during planetesimal formation and growth. To predict the diversity of exoplanet compositions, previous works modeled planetesimal composition as the equilibrium chemical composition of a protoplanetary disk at a single time. However, planetesimals form over an extended period of time, during which elements sequentially condense out of the gas as the disk cools and are accreted onto planetesimals. To account for the evolution of the disk during planetesimal formation, we couple models of disk chemistry and dynamics with a prescription for planetesimal formation. We then follow the growth of these planetesimals into terrestrial planets with N-body simulations of late-stage planet formation to evaluate the effect of sequential condensation on the bulk composition of planets. We find that our model produces results similar to those of earlier models for disks with C/O ratios close to the solar value (0.54). However, in disks with C/O ratios greater than 0.8, carbon-rich planetesimals form throughout a much larger radial range of the disk. Furthermore, our model produces carbon-rich planetesimals in disks with C/O ratios as low as ~0.65, which is not possible in the static equilibrium chemistry case. These results suggest that (1) there may be a large population of short-period carbon-rich planets around moderately carbon-enhanced stars (0.65 0.8).

M2K: II. A Triple-Planet System Orbiting HIP 57274

Doppler observations from Keck Observatory have revealed a triple-planet system orbiting the nearby K4V star, HIP 57274. The inner planet, HIP 57274b, is a super-Earth with M sin i = 11.6 M-circle plus (0.036 M-Jup), an orbital period of 8.135 +/- 0.004 days, and slightly eccentric orbit e = 0.19 +/- 0.1. We calculate a transit probability of 6.5% for the inner planet. The second planet has M sin i = 0.4 M-Jup with an orbital period of 32.0 +/- 0.02 days in a nearly circular orbit (e = 0.05 +/- 0.03). The third planet has M sin i = 0.53 M-Jup with an orbital period of 432 +/- 8 days (1.18 years) and an eccentricity e = 0.23 +/- 0.03. This discovery adds to the number of super-Earth mass planets with M sin i < 12 M-circle plus that have been detected with Doppler surveys. We find that 56% +/- 18% of super-Earths are members of multi-planet systems. This is certainly a lower limit because of observational detectability limits, yet significantly higher than the fraction of Jupiter mass exoplanets, 20% +/- 8%, that are members of Doppler-detected, multi-planet systems.

Novel Integration of Systems-Based Practice Into Internal Medicine Residency Programs: The Interactive Cost-Awareness Resident Exercise (I-CARE)

Background: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. Description: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. Evaluation: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees (

BUILDING MASSIVE COMPACT PLANETESIMAL DISKS FROM THE ACCRETION OF PEBBLES

1,027.45 vs.

Fiber Scrambling for High-Resolution Spectrographs. II. A Double Fiber Scrambler for Keck Observatory

4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. Conclusions: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

Assessing Resident Attitudes and Confidence after Integrating Geriatric Education Into a Primary Care Resident Clinic

We present a model in which planetesimal disks are built from the combination of planetesimal formation and accretion of radially drifting pebbles onto existing planetesimals. In this model, the rate of accretion of pebbles onto planetesimals quickly outpaces the rate of direct planetesimal formation in the inner disk. This allows for the formation of a high mass inner disk without the need for enhanced planetesimal formation or a massive protoplanetary disk. Our proposed mechanism for planetesimal disk growth does not require any special conditions to operate. Consequently, we expect that high mass planetesimal disks form naturally in nearly all systems. The extent of this growth is controlled by the total mass in pebbles that drifts through the inner disk. Anything that reduces the rate or duration of pebble delivery will correspondingly reduce the final mass of the planetesimal disk. Therefore, we expect that low mass stars (with less massive protoplanetary disks), low metallicity stars and stars with giant planets should all grow less massive planetesimal disks. The evolution of planetesimal disks into planetary systems remains a mystery. However, we argue that late stage planet formation models should begin with a massive disk. This reinforces the idea that massive and compact planetary systems could form in situ but does not exclude the possibility that significant migration occurs post-planet formation.

Increasing Resident Participation in Research: Capitalizing on Local Resources to Maximize Success

We have designed a fiber scrambler as a prototype for the Keck HIRES spectrograph, using double scrambling to stabilize illumination of the spectrometer and a pupil slicer to increase spectral resolution to R = 70,000 with minimal slit losses. We find that the spectral line spread function (SLSF) for the double scrambler observations is 18 times more stable than the SLSF for comparable slit observations and 9 times more stable than the SLSF for a single fiber scrambler that we tested in 2010. For the double scrambler test data, we further reduced the radial velocity scatter from an average of 2.1 m/s to 1.5 m/s after adopting a median description of the stabilized SLSF in our Doppler model. This demonstrates that inaccuracies in modeling the SLSF contribute to the velocity RMS. Imperfect knowledge of the SLSF, rather than stellar jitter, sets the precision floor for chromospherically quiet stars analyzed with the iodine technique using Keck HIRES and other slit-fed spectrometers. It is increasingly common practice for astronomers to scale stellar noise in quadrature with formal errors such that their Keplerian model yields a chi-squared fit of 1.0. When this is done, errors from inaccurate modeling of the SLSF (and perhaps from other sources) are attributed to the star and the floor of the stellar noise is overestimated.

The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Quality of Discharge Practices and Patient Understanding at an Academic Medical Center

We created web pages containing all documents related to doing research in residency: guidelines, applications, abstract deadlines to select meetings, formatted poster templates, and past residents’ abstracts, posters, and oral presentations. To increase mentor access, we invited 35 Yale General Internal Medicine (GIM) faculty to complete a form delineating their research skills and ideas for resident research projects, then distributed these to house staff.